A new decision by Covered California to adopt a policy that helps customers pay for high-cost speciality drugs sparked hope for an expanded state law that could assist thousands with HIV, diabetes, multiple sclerosis and other chronic illnesses, health advocates say.

Under last week’s policy change, a first in the nation, those who bought health plans through Covered California, the state’s health insurance plan exchange, will see their specialty drugs capped at $250 per month per prescription. Overall, the caps will range from $150 to $500 and were crafted to help reduce the monthly out-of-pocket costs for enrollees.

The policy change has cast a spotlight on a deficiency under the Affordable Care Act, health advocates said. While they applaud the now 5-year-old law for making most Americans eligible for health coverage regardless of preexisting conditions, the high cost of drugs keep those who suffer from chronic illnesses from receiving valuable treatment, said Anthony Wright, executive director for Health Access, a California-based consumer advocacy coalition.

Covered California’s policy change will help those who need these medications but who were forced to spend their entire maximum out-of-pocket costs, Wright said.

The change is not permanent and would be reviewed in a year, nor is it perfect because it excludes some insurance holders, Wright and others said. But it’s a good start, he added.

“The fact that this has been agreed to in the Covered California realm makes it much more likely that these policies get enacted permanently,” Wright said.

His group is supporting legislation that is winding its way through Sacramento. Known as AB 339, the proposed law mirrors Covered California’s change, but would place limits on how much health plans can charge enrollees for outpatient prescriptions permanently. It would set a monthly cap of as little as $124, Wright said.

“Consumers are being protected from the most outrageous costs (through Covered California) but still are paying a lot for these drugs,” Wright said. “We want to make sure these people have access.”

While praised for its decision, Covered California’s board was also criticized for not going far enough. California Insurance Commissioner Dave Jones said the $500 cap per prescription per month for those who carry a bronze plan was still too high.

“While I am pleased that Covered California took our suggestions to cap Silver, Gold and Platinum coverage, I am disappointed that Covered California did not lower the cap amount that health insurers can charge per drug per month for the bronze plans, as we requested,” Jones said in a statement.

More than 1.3 million Californians have active health insurance through Covered California. Of those, 24 percent have a bronze plan, which is most often purchased by those who consider themselves to be healthy and don’t want to pay a high premium.

“They can go further,” she said of Covered California’s decision. “The bronze plan is not a plan for people for chronic conditions. It’s not a good buy. We asked for a cap for $200, but we’re happy we got what we got. For the moment, we know there’s more work to do.”

Although some states have passed legislation to cap out-of-pocket costs for prescription drugs, Covered California’s decision made it the first exchange in the nation to do so.

“This is the first time that an exchange has ensured that all of its consumers have access to the medications they need,” Covered California Executive Director Peter Lee said in a statement. “These new policies strike a balance between ensuring Covered California consumers can afford the medication they need to treat chronic and life-threatening conditions while keeping premiums affordable for all.”

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